‘All or none’ does not apply to walking, anything is better than nothing

Walking below recommended levels is also associated with lower all-cause mortality, even if the recommended goal is not met says the results of large prospective cohort study published online in in the American Journal of Preventive Medicine.

The current public health guidelines recommend >150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity per week; a goal met by only 50% of US adults.

Walking is the most common form of moderate- or vigorous-intensity physical activity (MVPA), and is known to be associated with lower incidence of cardiovascular disease, type 2 diabetes, and breast and colon cancers. But, its association with all-cause mortality has not been examined so far.

The study looked at data from 62,178 men (mean age 70.7 years) and 77,077 women (mean age 68.9 years), who were followed up for a period of 13 years from 1999–2012. The researchers studied the effect of moderate- or vigorous-intensity physical activity (MVPA) on all-cause mortality.

During the study period, 24,688 men and 18,933 women died.

The mean age of men was 71 years and 69 years for women, about 5.8% of men and 6.6% of women reported no MVPA when the study started. These ‘inactive’ individuals were 26% (HR=1.26) likely to die prematurely as compared to subjects who were active but not to the recommended level (only for <2 hours/week).

Meeting the minimum recommendation of walking one or two times per week was associated with 20% lower risk of mortality (HR=.77) which was at par with any MVPA.

Walking that extra mile than what was recommended did not add any extra benefit and the benefits were equivalent to meeting the requirements.

Walking one or two times per week as per the minimum recommendation also reduced the CVD and cancer mortality by 20% and 9% respectively.

All these results were adjusted by sex, baseline age, BMI, prevalent disease status, and leisure-time sitting.

Alpa Patel, PhD, the lead author and researcher at the American Cancer Society opines, “walking has been described as the “perfect exercise” because it is a simple action that is free, convenient, does not require any special equipment or training, and can be done at any age.”

The walking intensity in this study was not ‘power walk’ or ‘strolling in the garden’ but average walking that may make you slight breathless and you cover about a mile in 20 minutes. This constitutes moderate intensity activity.

In absolute figures not corrected for the confounders, it was seen that there was 4293 per 100,000 deaths for inactive participants vs  2851 for walking less than the recommended amount. That is 1442 fewer deaths per 100,000 than inactive participants.

And the number of deaths were further reduced to 2088 per 100,000 for those who met the walking guidelines.

A lot of people are now a day do a walking meeting instead of sitting meeting in the office. 

The authors conclude, “This study shows that engaging in walking is associated with increased longevity and has the potential to improve the public’s health significantly.”

Media: wisegeek. 

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Johnson & Johnson to pay $417 million to a ovarian cancer patient: a blockbuster verdict by Jury

In a landmark decision, a jury has ordered Johnson & Johnson (J&J) to pay $417m (£323m) to a woman who claimed she developed ovarian cancer after using the company’s talc-based products such as Johnson’s Baby Powder for feminine hygiene.

The verdict was given in favor of California resident Eva Echeverria,who claimed that she developed terminal cancer after decades of use of J&J’s products.

This is the largest payout yet with J&J facing thousands of lawsuits (4800) for failure to warn the consumer about cancer risk of its talc based products.

“We are grateful for the jury’s verdict on this matter and that Eva Echeverria was able to have her day in court,” said Mark Robinson, her lawyer, in a statement.

Her lawyers argued that the company continued to market and encourage women to use its talc based products, despite aware of its carcinogenic potential.

Earlier, a Missouri jury has awarded $72 million to the family of an Alabama woman who died from ovarian cancer in October 2015.

Despite being named as baby powder, it is used by millions of adults in sensitive area to prevent  chafing or promote dryness.

In its natural form talc contains asbestos, a proven carcinogenic since decades.American Cancer Society states,” When talking about whether or not talcum powder is linked to cancer, it is important to distinguish between talc that contains asbestos and talc that is asbestos-free. Talc that has asbestos is generally accepted as being able to cause cancer if it is inhaled. This type of talc is not used in modern consumer products. The evidence about asbestos-free talc, which is still widely used, is less clear.”

It is postulated that if talc or a product containing talc is applied to your genital area in any way (whether it’s applied directly — what’s called perineal talc use —  or whether it makes its way there via pads, condoms, etc.), the powder particles might be able to travel from your vagina all the way up to your ovaries.

This may set off inflammation, which is believed to play an important role in etiology for ovarian cancer.

Many studies have looked into possible link between talc use and ovarian cancer, but the findings are equivocal. A 2003 meta-analysis of 16 studies (11,933 patients) found a link between talc use and ovarian cancer while a 2014 study of 61,576 women did not find the same link.

Meanwhile J&J said, “We will appeal today’s verdict because we are guided by the science, which supports the safety of Johnson’s baby powder.”

So, the bottom line is we still do not have sufficient evidence to prove causation. FDA states that, “There is not sufficient evidence to prove a possible connection.” However, after a flurry of recent lawsuits The U.S. FDA Office of Women's Health has agreed to fund a study investigating the possible link between cosmetic talc use and ovarian cancer.

A posting on the FDA's website notes that while women are commonly known to use products containing talc for hygiene and cosmetic purposes, talc's effects on the tissues that make up the female genital system have not been adequately investigated.

Till causation is proved, the consumers are advised to play it safe and can use talc free powders. A lot of companies make talc-free baby powder out of cornstarch, including Johnson & Johnson.

Is HPV testing ready to replace Pap testing as the first-line test for cervical cancer screening--News from ACOG Annual Clinical and Scientific Meeting 2016.

On Day 3 of the  Annual Clinical and Scientific meeting, ACOG  2016 the question at this year’s John and Marney Mathers Lecture was Is HPV testing ready to replace Pap testing as the first-line test for cervical cancer screening for women 25 and older?

Warner K. Huh, MD, professor and division director of gynecologic oncology, senior scientist in the University of Alabama-Birmingham (UAB) Comprehensive Cancer Center, and Margaret Cameron Spain endowed chair in Obstetrics and Gynecology at the UAB School of Medicine are positive about it while George F. Sawaya, MD, professor of Obstetrics, Gynecology and Reproductive Sciences and Epidemiology & Biostatistics at the University of California, San Francisco, argued for a more cautious approach during the morning session debate on May 16, 2016.

Dr. Huh believes that HPV testing has the most sensitivity and negative predictive value out of all the screening technologies. A negative result gives a long time assurance about absence of cervical malignancy. In support of his argument he cited the Canadian cervical cancer screening trial (CCCaST) of 10,171 women ages 30-69 randomized to HPV testing or pap test.  The results showed that verification-bias adjusted sensitivity of Pap cytology was 55.4% while that of HPV testing was 94.7%. Pap test also suffers from variation in collection, storage and lab performance.

He also said “Keep in mind that cytology has never been subject to a randomized control trial, and if you actually submitted the test to the FDA today, what’s interesting is that it would probably be resoundingly rejected by the FDA because of its low sensitivity.”

An aggregate of 4 studies published in the Lancet in 2011 found that when all the women who had a normal Pap test were analyzed there was rate of 7.5 instances of cancer per 100,000 women in a year while the same rate for HPV negative patients was 3.8 cervical cancers per 100,000. Women who were both HPV-negative and had a normal Pap test had 3.2 cervical cancers per 100,000.

Dr. Huh opined that when actually calculated it is 60% risk reduction in cervical cancer over the years. HPV screening further missed less cases when it comes to diagnosis of adenocarcinomas.

The Other Debater Dr. Sawaya said that major groups and association continues to discourage HPV testing in women younger than 30 independent of the COBAS HPV strategy of following up a positive test with HPV 16/18 type-specific testing followed by colposcopy, cytology or future follow-up.

He is also of the opinion that HPV testing will lead to more surveillance, uncertainty and confusion specially in the younger and the older age groups. A screening test must simplify life by maximizing benefits and avoiding life style disruptions, unnecessary surveillance, treatment and interventions.

He also talked about the ATHENA Trial, a US-based, 3 years’ multicenter study, comparing COBAS HPV vs. cytology (ASC-US+). According to him both techniques are at par when diagnosing CIN 2+ citing that in the ATHENA   trial a cohort of 1000 women, 25+ and older after the first round of screening, the HPV screening group found CIN2+ in eight women, while cytology found CIN 2+ in six.

The cytology group after the screening has had 10 percent abnormal cytology, 7 percent colposcopy and 5 percent in surveillance while those following COBAS algorithm had 21 percent HPV positive, 10 percent colposcopy and 19 percent in surveillance. The increased percentage of patients in surveillance does have increased psychological issues.

He suggests screening with cytology alone every three years, with HPV triage for ASC-US.

He further added “The loveliness of this strategy is that after a single screening round, they go to colposcopy or go back to routine screening. There’s not this middle ground of coming back in a year. There’s not this uncertainty.” 

But, ACOG does updated its guidelines on December 22, 2015 and the practice bulletin is cited here “The Practice Bulletin provides interim guidance on the use of the FDA-approved HPV test for primary cervical cancer screening, which it states can be considered as an alternative to current cytology-based cancer screening methods (the Pap test) in women 25 years and older. Women younger than 25 years should continue to be screened with cytology alone. Additional guidance is included that addresses a number of important clinical issues not specified in the FDA product labeling for the test, including when to rescreen after a negative test result, how to manage positive test results, and when to stop screening in women with negative screening histories.”

In addition, The Society of Gynecologic Oncology (SGO), the American Society for Colposcopy and Cervical Pathology (ASCCP), with input from representatives of five other US national medical organizations (ACOG, ACS, ASCP, ASC, CAP) issued an Interim Guidance Report after the U.S. Food and Drug Administration (FDA) approved the cobas® HPV Test as a primary, or first, test performed for cervical cancer screening.  This new guidance is in addition to the existing 2012 guidelines and specifically addresses the implementation of HPV testing in primary screening.

The guidance recommends:

• Primary HPV testing can be considered for women starting at age 25.
• Women with a negative primary HPV test result should not be retested again for at least three years. This is the same screening interval recommended under current guidelines for a normal cytology test result.
• An HPV test positive for HPV 16 or 18, two types associated with a higher risk of future disease, should be followed with colposcopy.
• A test that is positive for HPV types other than 16 or 18 should be followed with cytology testing.

References:

https://www.mcgill.ca/cccast/cccast-canadian-cervical-cancer-screening-trial

http://www.hpv16and18.com/hcp/cervical-cancer-screening-guidelines/new-us-primary-screening-guidance.html#sthash.Y5OzbJ7q.dpuf

http://www.acog.org/About-ACOG/News-Room/News-Releases/2015/ObGyns-Update-Cervical-Cancer-Screening-and-Prevention-Guidelines

USPSTF recommends biennial breast cancer screening beginning at age 50.

The USPSTF today once more made an important update to its 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for breast cancer. The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (B recommendation).These recommendations were published in the on-line issue of Annals of Internal Medicine on January 12, 2016.

Breast Cancer Screening Recommendations for Average-Risk Women

Agency issuing guidelines	Recommendations
USPSTF 2015
40–49 years	Screening decision should be an informed, individual one, after she weighs the potential benefit against the potential harms.( C recommendations )
50–74 years	Mammography every 2 years (B recommendation)
≥75 years	Data were not sufficient to establish the benefits of mammography screening in women aged 75 years or older.( I statement)
ACOG
40 years ≥	Annual mammograms beginning at age 40.
ACS
45 years	Annual screening beginning at age 45
45-54 years	Annual screening
55 and older	Transition to biennial screening or have the opportunity to continue screening annually depending upon personal preference. Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer
NCCN
40 years ≥	Clinical breast exam every 6-12 + annual mammogram beginning at age 40years. Upper age limit for screening not established; screening can continue if the woman is in good health and is expected to live at least 10 more years

  

Breast cancer is the second-leading cause of cancer death among women in the United States.

In 2015, an estimated 232 000 women were diagnosed with the disease and 40,000 women died of it.

There are approximately 125 new cases of breast cancer and about 22 deaths per 100 000 U.S. women each year. The mean age at diagnosis has remained unchanged at 64 years since the late 1970s.

It is most frequently diagnosed among women aged 55 to 64 years, and the median age of death from breast cancer is 68 years.

Across all ages, screening mammography has a sensitivity of approximately 77% to 95% and a specificity of about 94% to 97%

Dr.Christine Laine praises the USPSTF in an accompanying editorial saying that “The USPSTF did a difficult job well, considering updated evidence reviews, fuller panoply of potential harms, and tradeoffs of different screening strategies.”

She also said that “ Although for many years the dogma was that women should have mammograms “once a year for a lifetime” starting at age 40 years, current evidence shows that the balance of risks and benefits of screening, particularly among women in their 40s, warrants more nuanced decision making. Potential harms of over diagnosis and overtreatment of lesions with little progressive potential and harms of false-positive screening results with unnecessary biopsies and multiple repeated examinations must be considered”.

The following recommendation (originally issued in 2009) still stands: Each average-risk woman between the ages of 40 and 49 years should make her own decision about whether to have a mammogram, based on her personal balancing of the benefits and harms of screening (a grade “C” recommendation).

Benefit of Screening

Over a 10-year period, screening 10 000 women aged 60 to 69 years will result in 21 (95% CI, 11 to 32) fewer breast cancer deaths. The benefit is smaller in younger women: Screening 10 000 women aged 50 to 59 years will result in 8 (CI, 2 to 17) fewer breast cancer deaths, and screening 10 000 women aged 40 to 49 years will result in 3 (CI, 0 to 9) fewer breast cancer deaths.

Harms of screening

The harms of screening are over diagnosis and over screening that is diagnosis and treatment of non invasive and invasive cancer that would never have been detected in the absence of screening. Existing technology does not allow us to segregate with precision about how much is over diagnosis and how much was real diagnosis.

The best estimates from randomized, controlled trials (RCTs) evaluating the effect of mammography screening on breast cancer mortality suggest that 1 in 5 women diagnosed with breast cancer over approximately 10 years will be over diagnosed.

Based on data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program: The baseline breast cancer incidence rate was 105 to 111 cases per 100 000 women (depending on whether one considers invasive disease or invasive plus noninvasive disease together). With the widespread diffusion of mammography screening in last 30 years, this rate increased to 165 cases of noninvasive plus invasive disease per 100 000 women in 2011 (an excess of 54 to 60 cases per 100 000 women, or about a 50% increase).

Breast cancer mortality rates have declined at a slower rate, from 31 to 22 cases (or a reduction of 9 deaths) per 100,000 women over the same time period.

The USPSTF concludes that while there are harms of mammography, the benefit of screening mammography outweighs the harms by at least a moderate amount from age 50 to 74 years and is greatest for women in their 60s. For women in their 40s, the number who benefit from starting regular screening mammography is smaller and the number experiencing harm is larger compared with older women.

The current recommendations by USPSTF are based upon modeling studies conducted in support by the Cancer Intervention and Surveillance Modeling Network (CISNET). The investigators at CISNET evaluated data from six models that were grouped according to various screening strategies, various starting age and frequency.  The model with no screening served as reference.

It was seen that strategies involving screening every 2 years were consistently the most efficient for women at average risk for breast cancer.

The models showed that for women in the age group 50 to 74 years, biennial screening would prevent a median of seven breast-cancer deaths, compared with no screening vs. if the screening started at age 40, three additional breast cancer deaths would be prevented, but there would be 1988 more false-positive results and seven more over diagnoses for every 1000 women screened.

Dissatisfaction with the updated guidelines.

Many of the National agencies like National Comprehensive Cancer Network (NCCN) and M.D. Anderson Cancer Center are continue to screen women annually beginning at age 40 till she is within a decade of the predicted end of her life according to Therese Bevers, MD, medical director of the Cancer Prevention Center at the M.D. Anderson Cancer Center in Houston, and chair of NCCN guideline panels on breast cancer screening and diagnosis and breast cancer risk reduction.

National breast cancer screening programs in other countries like the United Kingdom,  Netherlands, Switzerland, Poland, Norway, Luxembourg, Germany, Finland, Denmark, and Belgium offer mammography screening every 2 to 3 years for women aged 50 up to 74 years.

References:

http://annals.org/article.aspx?articleid=2480757

http://annals.org/onlinefirst.aspx

http://www.medscape.com/viewarticle/857027#vp_3

http://jama.jamanetwork.com/article.aspx?articleid=2463262

http://jama.jamanetwork.com/article.aspx?articleid=2463261

http://annals.org/article.aspx?articleid=2480757#r50-2886

http://www.acog.org/Womens-Health/Breast-Cancer-Screening

http://ladiesfirstproviders.vermont.gov/sites/ladiesfirst/files/pdf/NCCN/breast-screening.pdf